Healthcare Provider Details

I. General information

NPI: 1477677003
Provider Name (Legal Business Name): SUSANNE M KUPKA-MOORE D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSANNE M KUPKA D.M.D.

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 DUNCAN ST
WARSAW NY
14569-1017
US

IV. Provider business mailing address

34 DUNCAN ST
WARSAW NY
14569-1017
US

V. Phone/Fax

Practice location:
  • Phone: 585-786-3676
  • Fax: 585-786-3896
Mailing address:
  • Phone: 585-786-3676
  • Fax: 585-786-3896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046184-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: